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Obs&Gynae > Induction And Augmentation Of Labor > Flashcards

Induction And Augmentation Of Labor Flashcards

1
Q

What is induction?

A

It is the planned initiation of labor prior to its spontaneous onset

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2
Q

How does induction work?

A
  • It ripens the cervix and initiates uterine contractions.
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3
Q

When should you carry out induction? (3)

A
  1. When there is a reasonable chance of success.
  2. When the risks of the process to the mother or fetus are acceptable.
  3. If there are no contraindications
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4
Q

What are the maternal and fetal indications for induction of labor? (9)

A

Maternal
- Post-term pregnancy
- Preeclampsia/eclampsia
- Maternal medical conditions (e.g., diabetes, chronic hypertension)
- Premature rupture of membranes (PROM) >24 hrs
-PPROM >34 weeks EGA
- chorioamnionitis

Fetal
- Fetal growth restriction
- Intrauterine fetal death
- Oligohydramnios

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5
Q

what are maternal contraindications for IOL (6)

A
  • Abnormal implanted placenta e.g. complete placenta previa
  • Active genital herpes/cervical cancer
  • History of uterine rapture
  • Previous VVF (vesicovaginal fistula) repair
  • Previous trans fundal surgery / cesarean section
  • poor condition of the mother (very ill and needs to be delivered soon-c/s)
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6
Q

what are fetal contraindications to IOL (6)

A
  • Malpresentation and abnormal lie
  • Macrosomia
  • Severe hydrocephalus
  • Severe fetal compromise i.e. non reassuring fetal heart tracing
  • Umbilical cord prolapse
  • Vasa previa
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7
Q

What is ripened cervix like ? (3)

A
  • softer
  • moving forward
  • starting to dilate.
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8
Q

what is a favorable bishops score

A

> 6

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9
Q

What are the 5 parameters of the modified bishops score

A
  • position of the cervix
  • length of the cervix
  • consistency of the cervix
  • dilatation of the cervix
  • station of the presenting part.
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9
Q

When the cervix hasnt yet ripened what will happen to IOL

A

it will take longer and sometimes likely fail

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10
Q

what are non pharmacological methods of IOL (5)

A
  • membrane sweeping
  • transcervical foley catheterization
  • balloon catheterization
  • amniotomy
  • nipple stimulation
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11
Q

Whats the aim of membrane sweeping

A

to release natural prostaglandins.

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12
Q

How does membrane sweeping work (2)

A
  • A gloved finger is inserted into the cervical Os in a circular movement to separate the chorionic membrane from the underlying decidua.
  • Women enter into labor in 48 hours
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13
Q

What are the risks of membrane sweeping (2)

A
  • rupture of membranes
  • vaginal bleeding
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14
Q

How does the transcervical foley catheterization work (5)

A
  • The Foley catheter is placed just above the internal cervical os. The catheter is then inflated with sterile saline or water(40-60ml)
  • The catheter needs to be tied to a leg for traction force
  • In the course of the pulling of the catheter by the traction force it applies pressure on the cervix leading to release of local prostaglandins. The traction force also leads to dilatation of the cervix
  • It comes out on its own
  • It can remain in place for more than 24 hours.
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15
Q

Whats the best mechanical way for ripening the cervix

A

Transcervical Foley catheterization

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16
Q

What are contraindications for the transcervical foley catheterization (4)

A
  • Low lying placenta
  • APH
  • ROM
  • evidence of lower tract infection
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17
Q

How does the balloon catheterization work (3)

A
  • works like transcervical Foley catheter but this has an addition balloon which sits just below the external os.
  • Thus, this applies pressure to both internal and external os.
  • This also stimulate release of natural prostaglandins
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18
Q

How does amniotomy work (3)

A
  • this is artificial rapturing of amniotic membranes using amniotic membrane perforator
  • This releases local prostaglandins causing cervical ripening and uterine contractions
  • Used in conjunction with oxytocin if uterine contractions havent yet started after 2hours of amniotomy
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19
Q

When should amniotomy be done

A

only if the fetal head is fully applied as risks of cord prolapse is very high

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20
Q

how does nipple stimulation work (2)

A
  • Stimulates uterine contractions likely by increasing oxytocin levels
  • Only feasible in women who have favorable cervix
21
Q

What are the pharmacological methods of IOL (4)

A
  • oxytocin
  • prostaglandin E1 (misoprostol)
  • prostaglandin E2 (dineprostone)
  • mifepristone
22
Q

How does oxytocin work (4)

A
  • Mimics natural endogenous oxytocin produced spontaneously during labor
  • Administered intravenously
  • Works by binding to G receptors in the myometrium which in turn leads to release of calcium ions from the endoplasmic reticulum into the cytoplasm. This leads to contractions of myometrium.
  • Start with low dose then increase every 30 minutes to achieve optical contraction of 3-5 every minute
23
Q

How does prostaglandin E1 work (2)

A
  • This can be administered intravaginally, orally, buccal and sublingually.
  • works by softening the cervix initiating uterine contractions and increasing the sensitivity of myometrial cells to oxytocin.
24
Q

What is the drug of choice in PROM

A

prostaglandin E1 (misoprostol)

25
Q

Whats the most commonly used prostaglandin

A

prostaglandin e2 (dineprostone)

26
Q

How does prostaglandin E2 work (2)

A
  • inserted intravaginally in the posterior fornix
    Found in three forms; tablet, gel and pessary
  • Works by softening the cervix, initiating uterine contractions and increasing the sensitivity of myometrial cells to oxytocin.
27
Q

what forms can prostaglandin E2 come in (3)

A
  • tablet
  • gel
  • pessary
28
Q

How does Mifepristone work

A

this is also called an anti-progesterone
it binds to progesterone receptors thus blocking progesterone one of the hormones which is needed for pregnancy to continue

29
Q

how do you induce labour in an unfavorable cervix (3)

A
  • Administer misoprostol and/or Foley catheter:
    For misoprostol you can dissolve 200mcg in 20ml and give 2.5ml of that solution orally every two hours
    You can also administer PV 25mcg every 4 hours up to 6 doses.
    You can also give 50mcg PV every 6 hours to a maximum of 4 doses
  • If not in active labor after 4 doses and fetal status is reassuring , rest pt for 24hrs and then restart induction or try an alternative agent such as foley bulb
  • If CTG is available perform NST before starting induction to assess if there is a reassuring pattern and no sign of fetal distress
  • Monitor all patients for uterine tachysystole (>5 contractions within a 10 min period averaged over 30 mins) throughout the induction
  • if there is tachysystole perform NST to assess fetal well being and place IV
30
Q

when shouldnt you give misoprostol if the cervix is unfavorable

A

if gestation age is greater or equal to 28 weeks plus a previous cesarean delivery because it poses a risk of uterine rupture

31
Q

How can you induce labour in a favorable cervix (4)

A
  • Amniotomy alone
  • Oxytocin alone
  • Oxytocin plus amniotomy if there is no contraindication
  • If membranes have already ruptured, oxytocin is as effective in labor induction and cervical ripening
32
Q

How do you induce labour in a previous cesarean delivery (4)

A
  • Start induction only with approval of senior
  • DO NOT USE misoprostol if ≥ 28 weeks GA
  • Consider amniotomy
  • Consider Foley catheter +/- oxytocin for cervical ripening
33
Q

how do you administer oxytocin (4)

A
  • Put 2.5 IU (multigravida) OR 5 IU (primigravida) in 1 liter of normal saline or ringers
  • Start with 10 drops then titrate it up by 15 drops per minute every 30minutes until you have strong contractions every 10 minutes. Maximum dose is 60 drops per minute
  • Monitor fetal status and maternal status continuously
  • Watch out for uterine hyperstimulation and uterine rapture
34
Q

What are factors for successful IOL (5)

A
  • Favorable cervix
  • Multiparity
  • Birthweight of <3500g
  • BMI<30
  • Gestation age
35
Q

what are risks and complications of IOL (7)

A
  • Atonic postpartum hemorrhage (oxytocin desensitization)
  • Uterine rupture
  • Fetal distress
  • Pain or discomfort
  • Increased chances of cesarean sections
  • Chorioamnionitis
  • Failure of induction
36
Q

What is labour augmentation

A

is the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labor.

37
Q

When do you augment in latent phase of labour

A

when it has prolonged and poor uterine contractions are assessed to be the underlying cause.

38
Q

when do you augment in active phase of labour

A

in both protracted and arrest disorders of labor

39
Q

What are the 2 types of arrest disorders

A
  1. Arrest of dilation in active phase
  2. Arrest of descent ( when there is no progress in the descent of the fetal presenting part during 2nd stage labor)
40
Q

What are the common methods for augmenting (2)

A
  • oxytocin
  • amniotomy
41
Q

what are the maternal and fetal contraindications of augmentation (6)

A

Fetal
- Abnormal lie and malpresentation of the fetus
- Obstructed labor ( shoulder dystocia, macrosomia)
- Features suggestive of compromises baby( fetal distress, unexplained oligohydramnios, IUGR)
Maternal
- Previous caesarean section
- Contracted pelvis
- Placenta previa

42
Q

What should you do prior to augmenting

A

confirm and document fetal wellbeing, presentation, current uterine activity and estimated fetal weight

43
Q

how do you augment a nulliparous or multigravida (P1-P4) (2)

A
  • Amniotomy

-Oxytocin: (2.5 IU (multigravida) and 5IU (primigravida) in 1 L NS or RL, starting at 10 dpm, then increase to 15 dpm after 30 minutes if tolerated and still no strong contractions, then start titrating up to by 15 dpm every 30 minutes until 3 strong contractions every 10 minutes, to maximum dose of 60 dpm)

44
Q

how to augment a grand multiparous (P5>) (2)

A
  • Amniotomy
  • Consider oxytocin after senior consultation
45
Q

If there is no change in cervical dilation within 4 hours after initiating augmentation what do you do?

A

stop the labor augmentation and proceed with cesarean delivery

46
Q

what are some complications of labour augmentation (4)

A
  • uterine rupture , from uterine hyper stimulation
  • Fetal compromise
  • PPH from uterine hyper stimulation causing uterine atony
  • hypotension
47
Q

What method of IOL would you use in someone with :
- pre eclampsia with severe features
- signs of IUGR
- or any other concerns for the fetus that still allow for IOL and does not require c/s

A

Consider foley bulb induction rather than misoprostol

48
Q

How do you manage augmentation of labor in a HIV infected woman (2)

A
  • There is no difference in management of augmentation if it’s obstetrically indicated
  • Delay amniotomy
49
Q

When should you reassess cervical dilation when augmenting labor

A

After 4 hours of at least 3 strong contractions every 10 mins to see if labor has progressed satisfactorily

50
Q

If labor hasn’t progressed during augmentation of labor what do you do

A

Consider amniotomy if not already done or c/s

Obs&Gynae (24 decks)

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